Guidelines for Malaria Prevention in Travellers from the UK 2015

Guidelines for malaria prevention in
travellers from the UK 2015

Guidelines for malaria prevention in travellers from the UK 2015
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About Public Health England
Public Health England exists to protect and improve the nation's health and wellbeing,
and reduce health inequalities. It does this through world-class science, knowledge and
intelligence, advocacy, partnerships and the delivery of specialist public health services.
PHE is an operationally autonomous executive agency of the Department of Health.
Public Health England
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Prepared by: PHE Advisory Committee for Malaria Prevention for UK Travellers
(ACMP)
For queries relating to this document, please contact: ACMPSecretariat@phe.gov.uk
© Crown copyright 2015
You may re-use this information (excluding logos) free of charge in any format or
medium, under the terms of the Open Government Licence v3.0. To view this licence,
visit OGL or email psi@nationalarchives.gsi.gov.uk. Where we have identified any third
party copyright information you will need to obtain permission from the copyright
holders concerned.
Published September 2015
PHE publications gateway number: 2015337
This document is available in other formats on request. Please email
ACMPSecretariat@phe.gov.uk

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Contents
About Public Health England 2
List of tables 5
List of figures 5
Executive summary 6
Abbreviations 8
1. General issues 10
1.1 How to give the advice 10
1.2 Medical history of the traveller 11
2. Awareness of risk 11
2.1 What is malaria? 11
2.2 Life cycle 12
2.3 The malarial illness 13
2.4 Where is malaria found? 15
2.5 Level of risk of exposure to malaria and what affects it 16
2.6 Distribution of drug resistant malaria 17
3. Bite prevention 17
3.1 When do female Anopheles mosquitoes bite? 17
3.2 Measures to prevent mosquito bites 18
4. Chemoprophylaxis 22
4.1 Principles 22
4.2 The drugs 23
4.3 Dosage tables 32
4.4 Country recommendations 35
4.5 Popular destinations 46
4.6 Emergency standby treatment 50
5. Diagnosis 52
5.1 Blood tests and how to request them in the UK 52
5.2 Rapid Diagnostic Tests (RDTs) 53
5.3 Blood film and/or RDT negative malaria 53
5.4 Resources for treatment advice 53
5.5 Notification 54
6. Special groups (medical conditions) 54
6.1 Smoking cessation 54
6.2 Pregnancy 54
6.3 Breastfeeding 56
6.4 Anticoagulants 57
6.5 Epilepsy 59
6.6 Glucose 6-phosphate dehydrogenase deficiency 59
6.7 Sickle cell disease and thalassaemia (84) 60

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6.8 Immunocompromised travellers 60
6.9 Liver disease 61
6.10 Renal impairment 62
6.11 Splenectomy 62
6.12 Acute porphyrias 63
7. Special categories 63
7.1 Children 63
7.2 Elderly travellers 64
7.3 Multi-trip travel 65
7.4 Cruises 65
7.5 Oil rigs 66
7.6 Visits to national parks 66
7.7 Stopovers 66
7.8 Last minute travellers 66
7.9 Visiting friends and relatives 67
7.10 Students and children at boarding school 68
7.11 The long-term traveller 69
7.12 Long term visitors to the UK returning to live in malarious parts of the world 73
8. Frequently asked questions 76
8.1 What malaria prevention should be advised for travellers going on cruises? 76
8.2 What alternative antimalarial drugs can be used for areas where chloroquine and
proguanil are advised if they are unsuitable for a particular traveller? 76
8.3 Which antimalarial can I give to a traveller with a history of psoriasis? 76
8.4 Which antimalarial can I give a traveller who is taking anticoagulants? 77
8.5 How long can a traveller take different antimalarial drugs? 78
8.6 Which antimalarial drugs are suitable for women during pregnancy? 80
8.7 Which antimalarial drugs can be taken by women breastfeeding? 81
8.8 Which antimalarial drugs can be given to babies and young children? 81
8.9 What is the easiest way to calculate the correct dose of chloroquine for babies and
young children? 82
8.10 Many travellers I see are travelling through areas where different antimalarials are
recommended as they progress through their journey. How do we advise these travellers?83
8.11 Which antimalarial drugs can I advise for a traveller who has epilepsy? 83
8.12 What do I advise for the traveller with Glucose 6-phosphate dehydrogenase deficiency?
83
8.13 What do I advise people working on oil rigs? 84
8.14 What do I advise for the traveller on a stopover? 84
8.15 Can doxycycline affect oral contraception? 85
8.16 What advice can I give to travellers who discontinue chemoprophylaxis on or after
return to the UK due to drug side-effects? 85
8.17 What alternative antimalarial drugs can be used for Central America (and Dominican
Republic/Haiti) if chloroquine is unsuitable for a traveller? 85
9. Information resources 86
9.1 Expert centres 86
9.2 Useful websites 87
9.3 Information leaflets 88
Appendices 89
Appendix 1a: ACMP - Terms of reference 2015 89

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Appendix 1b: ACMP - Member list 91
Appendix 1c: ACMP - Conflict of interest statements 92
Appendix 1d: ACMP - Methodology 93
Appendix 2: Template for risk assessment and summary of advice given 96
Appendix 3: Emergency standby medication: traveller information leaflet 99
Reference list 102
List of tables
Table 1 Plasmodium species that infect humans ..................................................................... 12
Table 2 Clinical symptoms and signs of malaria (from the ACMP malaria treatment guidelines)
................................................................................................................................................. 14
Table 3 Prophylactic regimens against malaria in adults ......................................................... 32
Table 4 Doses of prophylactic antimalarials for children .......................................................... 33
Table 5 Table of doses by spoon or syringe measures for chloroquine syrup ......................... 34
Table 6 Table of paediatric dose of atovaquone/proguanil....................................................... 34
Table 7 Country recommendations .......................................................................................... 36
Table 8 Emergency standby treatment for adults................................................................. 51
Table 9 Doses of proguanil in adults with renal failure ............................................................. 62
Table 10 Long term chemoprophylaxis for adults..................................................................... 75
Table 11 Half-lives of selected antimalarial drugs .................................................................... 75
List of figures
Figure 1 The malaria life cycle ................................................................................................. 13
Figure 2 The spatial distribution of Plasmodium falciparum ..................................................... 15
Figure 3 Map of Bangladesh showing the areas with appropriate malaria prevention measures
recommended .......................................................................................................................... 46
Figure 4 Map of Brazil showing the states with appropriate malaria prevention measures
recommended .......................................................................................................................... 47
Figure 5 Map of India showing the states with appropriate malaria prevention measures
recommended .......................................................................................................................... 48
Figure 6 Map of South Africa showing the areas with appropriate malaria prevention measures
recommended .......................................................................................................................... 49
Figure 7 Cumulative risk of adverse events and malaria.......................................................... 71

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Executive summary
These practical guidelines from the Public Health England (PHE) Advisory Committee
on Malaria Prevention (ACMP) are updated and reissued annually. They are intended
for use by healthcare workers who advise UK-based travellers to malaria-endemic
areas but may also be of use to prospective travellers who wish to read about the
options themselves.
The ACMP prophylaxis guidelines are intended for UK-based travellers and may not be
appropriate for use by those residing in endemic areas.
Malaria prevention advice involves a combination of preventive measures (the ABCD of
malaria prevention) including:
 Awareness of risk
 Bite prevention
 Chemoprophylaxis
 Diagnose promptly and treat without delay
Recommendations for antimalarials should be appropriate for the destination and
tailored to the individual, taking into account possible risks and benefits to the traveller.
As part of an individual stringent risk assessment it is essential that a full clinical history
is obtained, detailing current medication, significant health problems and any known
drug allergies.
While the focus of these guidelines is on malaria prevention, it should be emphasised
that malaria prevention is only one aspect of pre-travel advice. A comprehensive risk
assessment-based package of travel health advice should be provided to the traveller.
Further resources for health professionals are listed in Chapter 9.
This 2015 update of the guidelines includes the following key changes:
 updated guidance on the use of insect repellent and sun protection
 clarification on the use of hydroxychloroquine
 updated guidance on the use of anticoagulants with antimalarials
 updated guidance on the use of doxycycline in epilepsy
 changes to the country recommendations for Vietnam and Malaysian Borneo,
and clarifications on the recommendations for India
 additional notes added at the beginning of the country recommendations table
including information about vulnerable travellers
 new malaria maps for India and South Africa have been provided by NaTHNaC
 clarification of advice for travellers moving through areas where different
antimalarials are recommended

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 details about ACMP added (see Appendices 1a-d) including : membership,
terms of reference and methodology used to make recommendations
These guidelines are available on the PHE website at
https://www.gov.uk/government/collections/malaria-guidance-data-and-analysis. This
site should be checked regularly for subsequent updates and practitioners should
ensure that they always use the latest version as recommendations may change.
Authorship
This guidance was written on behalf of the PHE ACMP by Professor Peter Chiodini, Dr
Dipti Patel, Professor Christopher Whitty and Professor David Lalloo (ACMP Chair).
Acknowledgements
Marie Blaze and Valerie Smith (PHE Malaria Reference Laboratory) for advice on
country tables and maps, Jon White (PHE) for help with publication and for drawing
maps, Dr Ian Williams for advice on chemoprophylaxis in HIV-infected travellers, Dr
Hannah Cohen for advice on anticoagulants, and Mustafa Kamara and Jo Freedman
(PHE Travel and Migrant Health Section) for providing secretariat support. PLC is
supported by the National Institute for Health Research University College London
Hospitals Biomedical Research Centre and is very grateful to Mrs Jane Chiodini for her
understanding over weekends lost to writing these guidelines.
Citation
Chiodini PL, Patel D, Whitty CJM and Lalloo DG. Guidelines for malaria prevention in
travellers from the United Kingdom, 2015. London: Public Health England; September
2015.

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Abbreviations
AIDS Acquired Immune Deficiency Syndrome
ACMP Advisory Committee on Malaria Prevention for UK travellers
BIS British Infection Society
BNF British National Formulary
CDC Centers for Disease Control and Prevention
DEET N,N diethyl-m-toluamide (an insect repellent)
EDTA Ethylene diamine tetraacetic acid
FAQ Frequently asked question
GP General Practitioner
G6PD Glucose 6-phosphate dehydrogenase (a metabolic enzyme)
HIV Human immunodeficiency virus
HTD Hospital for Tropical Diseases
INR International Normalized Ratio
IPS International Passenger Survey
IPT Intermittent Preventive Therapy
LSHTM London School of Hygiene and Tropical Medicine
LSTM Liverpool School of Tropical Medicine
NaTHNaC National Travel Health Network and Centre
NNRTI Non-Nucleoside Reverse Transcriptase Inhibitor
MHRA Medicines and Healthcare products Regulatory Agency

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MRL Malaria Reference Laboratory
PHE Public Health England
PI Protease Inhibitor
PCR Polymerase Chain Reaction
POM Prescription Only Medicine
RDT Rapid Diagnostic Test
RSTM&H Royal Society of Tropical Medicine and Hygiene
SP Sulfadoxine/pyrimethamine
SPC Summary of Product Characteristics or ”data sheet”
TMHS Travel and Migrant Health Section
UK United Kingdom
VFR Visiting Friends and Relatives
WHO World Health Organization

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1. General issues
The ACMP prophylaxis guidelines are intended for UK-based visitors to malaria
endemic areas and may not be appropriate for use by those residing in endemic areas.
Whilst these guidelines deal with malaria, malaria prevention is only one aspect
of pre-travel advice. An overall risk assessment-based package of travel health
advice should be provided to the traveller. Guidance on risk assessment can be
obtained from the Yellow Book, NaTHNaC and TRAVAX (see information
resources, Chapter 9)
In these guidelines, which have been specifically developed for travellers from the UK,
there are a small number of instances where the advice given differs from that in
guidelines from other countries or the World Health Organization. This is because
travellers from the UK do not usually visit all possible localities of malaria-endemic
countries and may not visit the same localities as travellers from other countries. Many
travellers from the UK who enter malaria-endemic countries are visiting friends and
relatives in localities from which people tend to migrate to the UK. They do not therefore
suffer exactly the same patterns of malaria exposure as permanent residents or visitors
from other cultures.
1.1 How to give the advice
Emphasise to the traveller the ABCD of malaria prevention:
Awareness of risk
Bite prevention
Chemoprophylaxis
Diagnose promptly and treat without delay
 emphasise that while no regimen is 100% effective, the combination of
preventive measures advised will give significant protection against malaria
 make use of visual aids, especially malaria distribution maps and show
examples of the preventive measures advised, such as aids to bite prevention
 based on individual risk assessment discuss the choices of chemoprophylaxis
regimens and their individual advantages and disadvantages, including cost
 provide the traveller with written information on malaria and its prevention.
Public Health England has an information leaflet in Bengali, Gujarati, Punjabi
and Urdu, in addition to English, which may be downloaded, photocopied and
distributed free of charge (see Chapter 9)

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1.2 Medical history of the traveller
is obtained, detailing current medication including those drugs prescribed by hospitals
which may not appear on GPs’ drug lists for repeat prescriptions, significant health
problems and any known drug allergies.
Safe and effective malaria prevention requires a sound knowledge of the medical
history of the traveller. When their patients seek pre-travel advice in primary care, this
information will be available from their own practice records but in the case of specialist
travel clinics malaria prevention advice may be sought at the first attendance. The
General Medical Council (1) stated "If you are not the patient's general practitioner and
you accept a patient for treatment without a referral from the patient's practitioner, then
you must: (a) Explain to the patient the importance and benefits of keeping their general
practitioner informed. (b) Inform the patient's general practitioner unless the patient
objects."
ACMP suggests that a written record of the malaria prevention measures advised is
given to the traveller so that they may pass it on to their GP. A template for risk
assessment and summary of advice given is provided at Appendix 2, which can be used
for gathering the information required for risk assessment when advising on malaria
prevention. It may be adapted for the particular circumstances of individual clinics.
2. Awareness of risk
2.1 What is malaria?
Malaria is a serious febrile illness due to infection of red blood cells with a parasite
called Plasmodium. It is transmitted by mosquitoes.
Five species of Plasmodium (P) regularly infect humans; see Table 1 below.
Mixed infections with more than one species of malaria parasite are not commonly
reported (21 in 2014).
In recent years, the incidence of P. vivax in UK travellers has dropped, but in regions where it is
a problem, the risk of acquiring vivax malaria is year round (2).

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Table 1 Plasmodium species that infect humans
Species Comment
Number of cases
reported in the UK in
2014 out of 15861
Plasmodium falciparum The most dangerous,
responsible for the vast
majority of malaria deaths
worldwide
1169 (74%)
Plasmodium vivax A relapsing malaria
See life cycle
225 (14%)
Plasmodium ovale A relapsing malaria
See life cycle
130 (8%)
Plasmodium malariae May present with late
recrudescence after many
years
41 (3%)
Plasmodium knowlesi Very rarely imported at
present, but capable of
producing severe illness
0
2.2 Life cycle
An infected mosquito inoculates 10 to 15 sporozoites when it bites. Each sporozoite
introduced into a human and successfully entering a liver cell develops in five to seven
days (P. falciparum) into a schizont containing approximately 30,000 offspring
(merozoites) which are released into the bloodstream when the schizont ruptures. Each
merozoite has the potential to infect a red blood cell. Once inside the red cell, the
malaria parasite grows and divides over 24 hours (P.knowlesi) 48 hours (P. falciparum,
vivax or ovale) or 72 hours (P. malariae) to form between 8 and 32 parasites,
whereupon the red cell bursts to release them to infect new red cells. These cycles in
the red cells continue, increasing the numbers of parasites in the infected person and
leading to clinical illness. Some parasites in the red cells do not divide but form sexual
stages (gametocytes) which mate if taken up by a biting female mosquito and thus
complete the malaria life cycle. Figure 1 shows the points in the life cycle at which
antimalarial preventive measures are targeted.
1
The UK malaria figures for the preceding January to December are released annually on World Malaria Day
(25th April) and can be accessed at https://www.gov.uk/government/collections/malaria-guidance-data-and-
analysis#epidemiology

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Figure 1 The malaria life cycle
2.3 The malarial illness
Malaria can neither be confirmed nor excluded by clinical features alone. The common
symptoms and signs are shown in Table 2. There may be no physical signs apart from
fever but it must be noted that even the absence of fever itself does not exclude the
diagnosis in an ill patient. There is a risk of misdiagnosing malaria as influenza or other
viral illness: viral hepatitis (if jaundice is present), gastroenteritis (if diarrhoea is evident)
or lower respiratory tract infection (cough can be a non-specific symptom).

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Table 2 Clinical symptoms and signs of malaria (from the ACMP malaria treatment guidelines)
Non-specific symptoms of malaria
Fever/sweats/chills
Malaise (vague discomfort)
Myalgia (muscle pain, tenderness)
Headache
Diarrhoea
Cough
Major features of severe or complicated falciparum malaria in adults
Impaired consciousness or seizures
Renal impairment (oliguria < 0.4ml/kg bodyweight per hour or creatinine >265μmol/l))
Acidosis (pH <7.3)
Hypoglycaemia (<2.2mmol/l)
Pulmonary oedema or acute respiratory distress syndrome (ARDS)
Haemoglobin ≤8g/dL
Spontaneous bleeding/disseminated intravascular coagulation
Shock (algid malaria)
Haemoglobinuria (without G6PD deficiency)
Major features of severe or complicated malaria in children
Impaired consciousness or seizures
Respiratory distress or acidosis (pH <7.3)
Hypoglycaemia
Severe anaemia
Prostration (inability to sit or stand)
Parasitaemia >2% red blood cells parasitised
“Once you get malaria it keeps coming back” – true or false?
Hypnozoite-induced relapses occur in vivax and ovale malaria, but can be treated
successfully and further relapses prevented. If the patient has received a full course of
treatment with modern antimalarial drugs and has not been re-exposed to malaria, it is
extremely unlikely that a history of recurrent febrile illness over a number of years is the
result of chronic malaria.

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Figure 2 The spatial distribution of Plasmodium falciparum
2.4 Where is malaria found?
Figure 2 shows the global distribution of falciparum and vivax malaria courtesy of the
Malaria Atlas Project (3). It is for illustration and should not be used to advise individual
travellers on chemoprophylaxis. Choice of preventive measures should be based on the
information stated in Table 7.
In-country maps of prophylactic advice linked to malaria distribution are available for
selected countries in these guidelines for use when advising individual travellers. The
likelihood of malaria transmission may vary considerably within one country.
Practitioners should be aware of the recent recognition of P. knowlesi as the fifth
malaria parasite of humans. It is a parasite of macaques and a zoonosis in humans in
the Asia-Pacific region. As its asexual cycle takes only 24 hours, it is possible for its
parasitaemia to rise more rapidly than with the other malaria species. A further danger
is its close morphological resemblance to P. malariae which is a much less severe
infection. Therefore, P. knowlesi should be urgently considered in any patient with

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malaria from the Asia-Pacific region with what appears to be P. malariae. Whilst P.
knowlesi is a zoonosis and thus not amenable to control in the same way as those
parasites which infect humans alone, prevention of human infection still relies on bite
prevention, awareness of risk and chemoprophylaxis. P. knowlesi is sensitive to
chloroquine.
2.5 Level of risk of exposure to malaria and what affects it
Exposure of individual travellers to malaria is influenced by the number of infectious
bites received. Factors affecting the number of infectious bites received are given
below.
Temperature, altitude and season:
 the optimum conditions for malaria transmission are high humidity and an
ambient temperature in the range 20 to 30°C (4).
 malaria transmission does not usually occur in regions with temperatures below
the 16°C isotherm (line on a weather map joining all the places that have the
same temperature)
 parasite maturation in the mosquito usually cannot take place at altitudes
greater than 2000 metres. However, it has been reported at altitudes up to 2500
metres in some countries
 seasonal rainfall increases mosquito breeding and in some areas malaria is
highly seasonal
Rural versus urban location:
 malaria incidence is generally higher in rural than in urban areas, especially in
Africa where the intensity of transmission is on average about 8 times higher in
villages than towns (5) but as Africa becomes increasingly urbanised, the risk of
contracting malaria in African or other cities of malaria-endemic areas must not
be discounted (6)
Type of accommodation:
 an impregnated bed net should be used unless the accommodation is fitted with
functioning air-conditioning and windows and doors which are sufficiently well
sealed to prevent mosquito entry
 backpackers staying in cheap accommodation have a higher risk of being bitten
compared to tourists staying in air-conditioned hotels
 the traveller should embark on their journey equipped with mosquito protection
measures appropriate to their particular circumstances

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Patterns of activity:
 being outdoors between dusk and dawn when Anopheles mosquitoes bite
increases the risk
Length of stay:
 the longer the stay, the higher the risk of contracting malaria
2.6 Distribution of drug resistant malaria
 chloroquine-resistant falciparum malaria is now widespread (effectively
universal)
 P. falciparum has also developed resistance to a variety of other agents in
certain areas. Further comment on the extent and severity of drug resistance is
given in the country table in Chapter 4
 there is currently no recorded drug resistance to P. ovale and only one report of
drug-resistant P. malariae (to chloroquine) (7)
 chloroquine-resistant P. vivax is found in the Indonesian archipelago; the Malay
Peninsula, including Myanmar, and eastward to Southern Vietnam and may
have spread further (8)
 P. vivax with reduced susceptibility to primaquine is found in South-East Asia
and Oceania and higher doses of primaquine are required to achieve radical
cure of this parasite from those areas. A higher dose may also be required for
P. vivax from India, Pakistan, Afghanistan and South America (8)
3. Bite prevention
Effective bite prevention should be the first line of defence against malarial infection.
3.1 When do female Anopheles mosquitoes bite?
Biting time varies between species, so travellers should assume they are at risk of being
bitten from dusk to dawn inclusive. The biting of several major malaria vectors in Africa
peaks at and just after midnight so protection in bed is especially important. However, in
many parts of South America and South East Asia, the greatest risk from being bitten by
malaria vectors is in the evening, before the population retires indoors. Furthermore, as
other species of mosquito eg those which transmit yellow fever, dengue fever and other
arboviral infections, bite during the daytime, it would be prudent also to maintain bite
precautions during daylight hours.

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3.2 Measures to prevent mosquito bites
3.2.1 Repellents
ACMP recommends DEET-based insect repellents as concentrations over 20% give a
longer duration of protection than currently available formulations of other agents. If
DEET is not tolerated (or is not available), an alternative preparation should be used,
but few are as effective as DEET (see below) (9).
DEET
DEET (N,N-diethyl-m-toluamide) has been in use as an insect repellent for more than
50 years and is reportedly used worldwide by approximately 200 million people each
year (10). It is available in a variety of concentrations and in various preparations
including sprays and a slow release polymer. A variety of studies has concluded that
there is a low risk of adverse effects when DEET is applied according to product
directions (10).
As a guide, duration of protection is 1 to 3 hours for 20%, up to 6 hours for 30% and up
to 12 hours for 50% DEET. There is no further increase in duration of protection beyond
a concentration of 50% (11). Sweat-off time varies with activity. The interval between
applications depends on this as well as the DEET formulation and concentration used.
DEET and sunscreen
Several studies have studied the impact of co-application of sunscreen and DEET.
DEET (33 %) has been shown to decrease the protection from SPF 15 sunscreen (12)
but there is no evidence that sunscreen reduces the efficacy of DEET when used at
concentrations above 33 % (13, 14). Frequent (every 2 hours) reapplication of
sunscreen over DEET applied at below the recommended 20 % (17 %), was found to
reduce the mean repellency rate and also mean protection time (by about one hour)
compared with DEET alone (14).
Stanczyk et al (15) recommended advising travellers to: apply repellent first; use a
combined repellent and sunscreen product; be aware that repellent may wear off more
quickly if reapplying only sunscreen on top.
New ACMP recommendation for 2015: Repellent activity will reduce more quickly than
that of a sunscreen if reapplying only sunscreen on top and repellent will therefore
usually need to be reapplied on top of a sunscreen. When both sunscreen and DEET
are required, DEET should be applied after the sunscreen. 30 to 50 SPF
sunscreen should be applied to compensate for DEET-induced reduction in
SPF. Sunscreen is not required from dusk to dawn.

19
DEET is not recommended for infants below the age of 2 months.
Use of 20% DEET in the second and third trimesters of pregnancy was not associated
with adverse effects on infants from those pregnancies followed for up to 12 months
after birth (16). Given the seriousness of malaria in pregnancy, ACMP recommends the
use of DEET at a concentration of up to 50% as part of the malaria prevention regimen
for pregnant women, including those in the first trimester. DEET may be used at a
concentration of up to 50% in breast feeding and for infants and children aged over 2
months.
ACMP advice on use of DEET for protection from mosquito bites:
 DEET is suitable for all individuals over the age of 2 months (unless allergic)
 50% has the longest duration of action, and needs fewer applications per day
 there is no current evidence that any group (including pregnant women and small
children) is at increased risk from using 50% DEET
 lower concentrations are available:
o they need more frequent application and may not be as effective as 50%
o care must be taken to re-apply or use a higher concentration DEET preparation
if mosquito biting occurs after their use
o lower concentrations are not suitable for individuals who may expect prolonged
exposure, such as that encountered by backpackers and expedition travellers
o ACMP considers concentrations below 20% inappropriate in almost any
circumstances
 DEET applications can damage some plastic watch straps, watch 'glasses' and
plastic jewellery; these items should not be allowed to come into contact with DEET
 the user should ensure that repellents are not ingested or inhaled and do not come
into contact with their eyes or mouth. Repellents should be used only on exposed
areas of skin
p-menthane 3,8 diol (lemon eucalyptus)
p-menthane 3,8 diol (PMD) gives about the same amount of protection afforded by 15%
DEET (17) but is reported to provide a shorter period of protection than extended
duration (microencapsulated) DEET (18).
Icaridin (Picaridin)
Icaridin (KBR3023) (1piperidinecarboxylic acid, 2-(2hydroxyethyl)-,1-methyl-propylester)
is reported to have repellent properties comparable to those of DEET (19-21). Icaridin is
available in various concentrations (22, 23). If a traveller elects to use icaridin for
mosquito bite prevention, ACMP advises use of at least a 20% preparation.

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3-ethlyaminopropionate
3-ethlyaminopropionate (IR3535) has a shorter duration of protection than DEET (20,
24) which gives protection times against Anopheles 20 to 25% higher than IR3535 at
equal concentrations (25).
Oil of citronella
While oil of citronella-based products do have repellent properties, they provide short-
lived protection (24) and are not recommended by ACMP. Citronella has been
withdrawn in Europe.
3.2.2 Insecticides
Permethrin and other synthetic pyrethroids have a rapid knock-down effect on
mosquitoes and are used to kill resting mosquitoes in a room.
3.2.3 Nets
If sleeping outdoors or in unscreened accommodation, insecticide-treated mosquito nets
should be used. Protective efficacy for travellers has been estimated at 50% (26).
Mosquito bed nets must be free of tears and should be tucked in under the mattress.
Insecticide (pyrethroid)-impregnated bed nets improve protection because they help to
prevent (a) biting through the net on parts of the body touching the net, (b) mosquitoes
surviving long enough near a net to find any tears in the net which may exist (c)
diversion of mosquitoes from someone under a net to someone in the same room
without a net (27). Most of the nets now available are long-lasting impregnated nets. In
these products the pyrethroid is incorporated into the material of the net itself or bound
to it with a resin (28). They have an expected useful life of at least 3 years. If using
standard nets these will need to be re-impregnated every 6 to 12 months (depending on
how frequently the net is washed) to remain effective (29). If a traveller purchases a
standard impregnated net, the 6 months starts from the date when it starts to be used
and washed, as washing and handling are the main factors removing the pyrethroid.
3.2.4 Clothing
Within the limits of practicality, cover up with loose-fitting clothing, long sleeves, long
trousers and socks if out of doors after sunset, to minimise accessibility to skin for biting
mosquitoes. There is no evidence that the colour of clothing is relevant to mosquitoes.
Clothing may be sprayed or impregnated with an insecticide, eg permethrin (29) or
purchased pre-treated to reduce biting through the clothing. As an alternative, cotton
clothing (eg socks) can be sprayed with DEET. It is useful as a clothing repellent but its
duration on clothing is shortened due to its volatility (30).

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3.2.5 Room protection
Air conditioning reduces the likelihood of mosquito bites as a result of substantial
reduction in night time temperature. Ceiling fans reduce mosquito nuisance.
Doors, windows and other possible mosquito entry routes to sleeping accommodation
should be screened with fine mesh netting which must be close-fitting and free from
tears.
The room should be sprayed before dusk with a knockdown insecticide (usually a
pyrethroid) to kill any mosquitoes which may have entered the accommodation during
the day.
During the night, where electricity is available, use a proprietary heated liquid reservoir
device containing insecticide or an electrically heated device to vapourise a “mat”
(tablet) containing a synthetic pyrethroid in the room. A new mat is needed each night.
Burning of a mosquito coil containing insecticide is an alternative which can repel and
kill mosquitoes (31) but is not recommended for use indoors.
3.2.6 Fallacies
Herbal remedies
The ACMP strongly advises against relying on any herbal remedies for the prevention of
malaria. Herbal remedies have not been tested for their ability to prevent or treat
malaria.
Homoeopathy
The ACMP strongly advises against relying on any homoeopathic remedies for the
prevention of malaria. There is no scientific proof that homoeopathic remedies are
effective in either preventing or treating malaria. In addition, the Faculty of
Homoeopathy does not promote the use of homoeopathic remedies for malaria
prevention.
Buzzers
Electronic buzzers (emitting high frequency sound waves) are completely ineffective as
mosquito repellents. Companies selling them have been prosecuted and fined under the
UK Trades Descriptions Act and ACMP advice is that they should not be used.
Vitamin B1
There is no evidence that vitamin B1 taken orally repels mosquitoes (32, 33).
Vitamin B12
There is no evidence that vitamin B12 taken orally has a repellent effect on mosquitoes.

22
Garlic
There is no evidence that garlic taken orally repels mosquitoes (34).
Savoury yeast extract spread
It is sometimes stated that Marmite® taken orally repels mosquitoes either by giving off
a cutaneous odour repellent to mosquitoes or via its vitamin B1 content. There is no
evidence that either assertion is true.
Tea tree oil
There is no evidence that tea tree oil is an effective mosquito repellent.
Bath oils
There is no evidence that proprietary bath oils provide effective protection against
mosquito bites.
4. Chemoprophylaxis
Recommendations for antimalarials should be appropriate for the destination and
tailored to the individual, taking into account possible risks and benefits to the traveller.
is obtained, detailing current medication, significant health problems and any known
drug allergies. For a suggested risk assessment template see Appendix 2.
Given the possibility of antimalarials purchased in the tropics being fake or sub-standard
(35), travellers should obtain the medication required for their chemoprophylaxis from a
reputable source in the UK before they travel. ACMP advises those purchasing
antimalarial drugs over the internet to ensure that they are dealing with a bona fide
supplier or web site.
4.1 Principles
Causal prophylaxis
Causal prophylaxis is directed against the liver stage of the malaria parasite, which
takes approximately 7 days to develop (see life cycle in Figure 1). Successful drug
activity at this stage prevents the parasite from progressing to infect red blood cells.
Causal prophylactics need to be continued for approximately 7 days after infection (36),
so ACMP recommends that they are continued for 7 days after leaving a malarious area
(see Table 3 of drug regimens in Chapter 4).

23
It is important not to confuse liver-stage schizonts with hypnozoites. All 5 species of
human malaria have liver-stage schizonts but only P. vivax and P. ovale have the
hypnozoite stage, against which causal prophylaxis is NOT effective.
Suppressive prophylaxis
Suppressive prophylaxis is directed against the red blood cell stages of the malaria
parasite and thus needs to be taken for several weeks to prevent infection (37).
Therefore, suppressive prophylactic drugs should be continued for 4 weeks after leaving
a malarious area (see drug regimens in Table 3, Chapter 4).
Prophylaxis against hypnozoites
P. vivax and P. ovale have a dormant stage called the “hypnozoite”. The hypnozoite
remains dormant for months and then “wakes up” to develop into a liver schizont. The
dormant hypnozoite explains why attacks of vivax or ovale malaria can occur long after
the end of chemoprophylaxis. This is not due to drug failure, as none of the prophylactic
drugs currently advised by ACMP acts against the hypnozoite stage of P. vivax or P.
ovale.
Primaquine is active against hypnozoites (present only in P. vivax and P. ovale) and is
used in the treatment of these forms of malaria. It also has causal prophylactic activity
against the liver stage schizonts of all malaria parasites of humans (38).
Primaquine is occasionally used for terminal prophylaxis (also known as presumptive
anti-relapse therapy) to eradicate hypnozoites of P. vivax and P. ovale. However, the
routine use of primaquine for prophylaxis is not recommended by ACMP.
Primaquine is not licensed in the UK and practitioners considering the use of
primaquine as a prophylactic agent should consult an expert centre (see Chapter 9).
Primaquine is an oxidant drug and can lead to significant haemolysis in G6PD-deficient
individuals.
4.2 The drugs
The British National Formulary (BNF) contains full listings of drug actions, dosages, side
effects, interactions and contraindications summarised here and should be consulted as
required when recommending malaria chemoprophylaxis. ACMP guidance on individual
drugs is not as detailed as that provided for prescribers in manufacturers’ information
sheets.
Chapter 6 of these guidelines also provides details of contraindications for different
medical conditions such as pregnancy and renal impairment.

24
NOTE: All adverse events of medication, including attacks of malaria, should be
reported. Anybody from the UK, including members of the public, can report any
suspected side effects from malaria medicines via the Yellow Card Scheme on the
Medicines and Healthcare products Regulatory Agency (MHRA) website.
www.mhra.gov.uk
These drugs are not listed in order of preference.
4.2.1 Chloroquine
Mode of action
Chloroquine is concentrated in the malaria parasite lysosome and is thought to act by
interfering with malaria pigment formation, causing generation of a ferriprotoporphyrin
IX-chloroquine complex which is highly toxic to the parasite.
Efficacy
Chloroquine-resistant falciparum malaria is now reported from all WHO regions except
Central America north of the Panama Canal and the Island of Hispaniola (Haiti & the
Dominican Republic). Prophylaxis with chloroquine as a single agent is therefore rarely
appropriate (see Table 7). It remains effective against most P. vivax, all P. ovale, P.
knowlesi, and virtually all P. malariae.
Side-effects
The main side effects are gastrointestinal disturbances and headache. Convulsions are
recorded. Chloroquine may cause itching in persons of African descent.
Interactions
Drugs: Amiodarone (increased risk of ventricular arrhythmias); ciclosporin (increased
risk of toxicity); digoxin (possibly increases plasma concentration of digoxin); mefloquine
(increased risk of convulsions); moxifloxacin (increased risk of ventricular arrhythmias;
avoid concomitant use).
Vaccines: Chloroquine may suppress the antibody response to pre-exposure
intradermal human diploid cell rabies vaccine (39). This interaction is not seen when
rabies vaccine is given intramuscularly (the currently recommended mode of
vaccination in the UK).
Contraindications
Chloroquine prophylaxis may exacerbate psoriasis and myasthenia gravis. It is
contraindicated in those with a history of epilepsy.
The risk of epilepsy is higher in first degree relatives of those in whom this condition has
been diagnosed so it should be considered as part of risk assessment. Epilepsy in a

25
first-degree relative may not contraindicate the use of an antimalarial, but may influence
the choice of drug.
Cautions
Chloroquine is highly toxic in overdosage, so should be stored out of the reach of
children. In long term use, eye examinations every 6-12 months should be considered
after 6 years’ prophylactic usage, though the risk of retinopathy developing on
prophylactic dosage is considered to be very low (40). See also long-term traveller
section in Chapter 7.
Methods of administration
Tablets contain 155 mg chloroquine base; syrup contains chloroquine base 50 mg/5 ml
(see paediatric dosages in Tables 4 and 5). Adult dose 310 mg (2 tablets) weekly,
starting one week before entering a malarious area, continuing throughout the time in
the area and for 4 weeks after leaving the area.
4.2.1.1 Hydroxychloroquine
Hydroxychloroquine is usually used for the treatment of rheumatic diseases, in doses
greater than those needed for malaria prevention. Individuals already taking
hydroxychloroquine AND for whom chloroquine would be an appropriate malaria
chemoprophylactic agent, can remain on hydroxychloroquine and do not need to
transfer to chloroquine. If doubt exists, seek expert advice.
4.2.2 Proguanil
Mode of action
Proguanil is converted to an active metabolite cycloguanil which inhibits the enzyme
dihydrofolate reductase and interferes with the synthesis of folic acid. It acts as a
suppressive and also as a causal prophylactic (41). Proguanil itself has a second mode
of action, mediated by the parent drug rather than its metabolite, which produces
synergy with atovaquone (see atovaquone plus proguanil).
Efficacy
There are very few regions in the world where the local P. falciparum strains are fully
sensitive to proguanil, so prophylaxis with proguanil as a single agent is rarely
appropriate.
Side-effects
The principal side effects of proguanil are mild gastric intolerance and diarrhoea. Mouth
ulcers and stomatitis occur occasionally, particularly when combined with chloroquine.

26
Interactions
Drugs: May enhance the anticoagulant effect of warfarin. Absorption reduced by oral
magnesium salts. Antifolate effect is increased when given with pyrimethamine.
Vaccines: None reported
Contraindications
Allergy to proguanil
Cautions
Renal impairment. Pregnancy (folic acid 5mg daily required for at least the first
trimester).
100mg tablets only. Adult dose 200 mg daily, starting one week before entering a
malarious area, continuing throughout the time in the area and for 4 weeks after leaving
the area.
4.2.3 Chloroquine plus proguanil
For side effects, interactions, contraindications and methods of administration, please
see individual agents.
ACMP does not recommend the use of chloroquine plus proguanil for travellers to sub-
Saharan Africa. If no alternative is felt to be appropriate, the matter should be discussed
with an expert centre (see Chapter 9).
4.2.4 Mefloquine
Mode of action
Mefloquine’s mode of action has not been determined, but is thought to be unrelated to
that of chloroquine and not to involve an anti-folate action. It acts as a suppressive
prophylactic.
Efficacy
The protective efficacy of mefloquine is 90% or more (42, 43). At the present time,
significant resistance of P. falciparum to mefloquine is a problem only in some areas of
south-East Asia (44), but is reported sporadically from the Amazon basin.
Side-effects
ACMP is not aware of any new data on side-effects since the 2014 update, but attention
has focused on neuropsychiatric problems and vestibular disorders with mefloquine
prophylaxis. Increased neuropsychiatric adverse events have been found, especially in
women using mefloquine, when compared with those receiving doxycycline, or

27
atovaquone plus proguanil, but not those taking chloroquine plus proguanil (45) but
there is no evidence that mefloquine use increases the risk of first-time diagnosis of
depression though it may increase the risk of psychosis and anxiety reactions (42, 46)
and no association between mefloquine prescriptions and hospitalisation (47).
Dizziness, balance disorder, tinnitus and vertigo may occur. In a small number of
patients it has been reported that dizziness or vertigo and loss of balance may continue
for months after discontinuing the drug. Overall, mefloquine remains an important
prophylactic agent which is tolerated by the majority of travellers who take it (42, 48).
Interactions
Drugs: Mefloquine antagonises the anticonvulsant effect of antiepileptics and interacts
with a number of cardiac drugs. Mefloquine is metabolised in the liver by CYP3A4.
Caution if administered with drugs inhibiting this enzyme (eg itraconazole) (42).
Ritonavir levels are reduced by mefloquine due to decreased absorption, but the clinical
significance of this interaction is unknown.
Contraindications
See also the manufacturer’s SPC.
As with any antimalarial, stringent risk assessment is required before advising
mefloquine use.
Mefloquine prophylaxis is contraindicated in those currently receiving halofantrine or
those with:
 hypersensitivity to quinine or quinidine
 a current or previous history of depression, generalized anxiety disorder, psychosis,
schizophrenia, suicide attempts, suicidal thoughts, self-endangering behaviour or
any other psychiatric disorder, epilepsy or convulsions of any origin. The risk of
epilepsy and serious mental health disorders is higher in first degree relatives of
those in whom these conditions have been diagnosed so they should be considered
as part of risk assessment. A condition in a first-degree relative may not
contraindicate the use of an antimalarial, but may influence the choice of drug
 a history of Blackwater fever
 severe impairment of liver function
Use of a checklist should ensure that proper screening is undertaken prior to mefloquine
administration and these contraindications are followed (49).
Cautions
Pregnancy (see Chapter 6, special groups); breast-feeding (see Chapter 6, special
groups); cardiac conduction disorders. Not recommended in infants under 5kg.
The SPC suggests that periodic checks on liver function and eye assessments should
be taken if mefloquine is used for a prolonged period. Any person taking mefloquine

28
presenting with a visual disorder should be referred to their treating physician as this
may require stopping chemoprophylaxis.
In those who have suffered traumatic brain injury, the decision whether or not to advise
mefloquine chemoprophylaxis should be made on an individual basis after a detailed
risk assessment.
Can mefloquine be taken by those who plan to undertake underwater diving?
If the individual tolerates mefloquine prophylaxis, there is no evidence that they cannot
physically perform underwater diving. However, mefloquine does lower the seizure
threshold and its side effects could potentially be confused with decompression or
narcosis events. It should also be noted that some sub-aqua centres do not permit
those taking mefloquine to dive. Mefloquine might therefore be better avoided for those
undertaking diving holidays but there is no contraindication to its use in occasional
divers who have taken and tolerated the drug before, or those able to start taking it early
to ensure that no adverse events occur.
Pilots
The UK Civil Aviation Authority advises that mefloquine should not be administered to
pilots, although there is no evidence that mefloquine impairs function.
Oral. 250mg tablets. Weekly dosage, starting 2-3 weeks before entering a malarious
area to assess tolerability, continuing throughout the time in the area and for 4 weeks
after leaving the malarious area.
4.2.5 Doxycycline
Mode of action
Doxycycline is lipophilic and acts intracellularly, binding to ribosomal mRNA and
inhibiting protein synthesis. It acts as a suppressive prophylactic.
Efficacy
Doxycycline is of comparable prophylactic efficacy to mefloquine (50).
Side-effects
Doxycycline hydrochloride preparations have a low pH and may produce oesophagitis,
especially if taken on an empty stomach and/or just before lying down. Doxycycline may
cause photosensitivity which is mostly mild and transient (51).
Doxycycline is a broad spectrum antibiotic and may predispose to vaginal candidiasis
(52).

29
Interactions
Drugs: The metabolism of doxycycline is accelerated by carbamazepine and phenytoin.
In that situation try to advise another antimalarial. If not possible or acceptable to the
traveller, increase the dose of doxycycline to 100mg twice daily and counsel regarding
measures to minimise the risk of adverse events. Tetracyclines possibly enhance the
anticoagulant effect of coumarins (eg warfarin), and doxycycline may increase the
plasma concentration of ciclosporin.
Doxycycline is a non enzyme-inducing antibiotic. The Faculty of Sexual and
Reproductive Healthcare and the BNF advise that for combined oral contraceptives and
for progestogen only oral contraceptives additional precautions are not required when
using non enzyme-inducing antibiotics. However, if the traveller suffers vomiting or
diarrhoea, the usual additional precautions should be observed.
Vaccines: Possibly reduces the efficacy of oral typhoid vaccine if given simultaneously.
Preferably should not be started within 3 days after the last dose of vaccine.
Contraindications
Allergy to tetracyclines. Children under 12 years of age.
Pregnancy: The UK National Teratology Information Service states that doxycycline is
best avoided for antimalarial prophylaxis during pregnancy. However, if required before
15 weeks' gestation it should not be withheld if other options are unsuitable, see
www.toxbase.org (53). The course of doxycycline, including the 4 weeks after travel,
must be completed before 15 weeks’ gestation.
Breast feeding: The British National Formulary states that tetracyclines should not be
given to women who are breast feeding (54).
A Centers for Disease Control Expert Meeting on Malaria Chemoprophylaxis stated that
doxycycline is excreted at low concentrations in breast milk and that the American
Academy of Pediatrics assessed tetracycline as compatible with breast feeding (52).
ACMP's view is that doxycycline should not be used in breast feeding unless other
options are unsuitable and its use is felt to be essential.
Cautions
Hepatic impairment. Patients taking potentially hepatotoxic drugs. Myasthenia gravis.
Systemic lupus erythematosus.

30
Capsules (50 or 100mg) or dispersible 100mg tablets only (consult summary of product
characteristics pertaining to individual products). Dose 100mg daily, starting 1 to 2 days
before entering a malarious area, continuing whilst there and for 4 weeks after leaving.
Precautions in use
The prescriber should warn against excessive sun exposure (and advise on the correct
use of a broad spectrum sunscreen), the risk of vaginal candidiasis and the risk of
oesophagitis if taken on an empty stomach and/or lying down too soon after taking it.
Doxycycline should be swallowed whole with plenty of fluid during meals while sitting or
standing and the traveller should not lie down within an hour of taking it.
4.2.6 Atovaquone plus proguanil combination preparation
Mode of action
Atovaquone works by inhibiting electron transport in the mitochondrial cytochrome b-c1
complex, causing collapse in the mitochondrial membrane potential. This action is
potentiated by proguanil and is not dependent upon conversion to its metabolite
cycloguanil. Indeed, the combination remains effective in cycloguanil-resistant parasites
(55). Atovaquone/proguanil prevents development of pre-erythrocytic (liver) schizonts
(but not hypnozoites). It acts as a causal prophylactic agent, so needs to be continued
for only 7 days after leaving a malarious area (56). It also has activity against the
erythrocytic stages of malaria parasites and is useful for treatment.
Efficacy
Prophylactic efficacy against P. falciparum is 90% or more (57-65). There is less
published data on protection against P. vivax, but data available indicate that
atovaquone-proguanil is effective in the prevention of primary attacks of vivax malaria
(64, 66). However, like chloroquine-proguanil, mefloquine and doxycycline, it will not
protect against hypnozoite-induced episodes of P. vivax (or P. ovale) malaria.
Side-effects
The most frequent side-effects are headache and gastrointestinal upsets.
Interactions
For proguanil see proguanil section (above).
Drugs: Plasma concentration of atovaquone is reduced by rifabutin and rifampicin
(possible therapeutic failure of atovaquone, avoid concomitant use), tetracycline (clinical
significance of this is not known) and metoclopramide.
Antiretrovirals: Atovaquone possibly reduces plasma concentration of indinavir.
Atovaquone possibly inhibits metabolism of zidovudine (increased plasma

31
concentration). Avoid concomitant use of atovaquone with ritonavir-boosted protease
inhibitors and most non-nucleoside reverse transcriptase inhibitors. If use unavoidable
seek expert advice.
Vaccines: None reported.
Contraindications
Pregnancy: The BNF states “Manufacturer advises avoid unless essential.” ACMP
advises against the use of atovaquone/proguanil for antimalarial chemoprophylaxis in
pregnancy. However, if there are no other options, its use may considered in the second
and third trimesters after careful risk assessment. Inadvertent conception when using
atovaquone/proguanil is not an indication to consider termination of the pregnancy, as
no evidence of harm has emerged in data so far available (67).
Atovaquone/proguanil should generally be avoided in breast feeding, but ACMP advises
that atovaquone/proguanil can be used when breast-feeding if there is no suitable
alternative antimalarial.
Cautions
Renal impairment (avoid for malaria prophylaxis if eGFR less than 30 mL/minute/1.73
m2
) diarrhoea or vomiting (reduced absorption of atovaquone).
Tablets containing proguanil 100 mg and atovaquone 250 mg. Paediatric tablets
containing proguanil 25 mg and atovaquone 62.5 mg. Adult dose one tablet daily
starting 1 to 2 days before entering a malaria endemic area, continuing throughout the
time there and for 1 week after leaving. Paediatric dosage given in Table 6.

32
4.3 Dosage tables
These drugs are not listed in order of preference.
The preferred prophylaxis is determined by a full risk assessment for each individual
traveller.
Table 3 Prophylactic regimens against malaria in adults
Regimen
Dose for
chemoprophylaxis
Usual amount for tablet
(mg)
Areas of chloroquine-resistant P. falciparum
Mefloquine
Doxycycline
Atovaquone-proguanil
combination preparation
One tablet weekly
One tablet/capsule daily
One tablet daily
250
100
250 (atovaquone)
plus 100 (proguanil)
Areas of little chloroquine resistance; poorly effective where extensive resistance
Chloroquine
PLUS
proguanil
Two tablets weekly
PLUS
Two tablets daily
155 (base)
100
Areas without drug resistance
Chloroquine
OR Proguanil (if
chloroquine not suitable;
see text)
Two tablets weekly
Two tablets daily
155 (base)
100

33
Table 4 Doses of prophylactic antimalarials for children
Weigh
t in
kilogra
ms
Drug and tablet size
Chloroquine
155mg
Proguanil
100mg
Mefloquine
250mg
Doxycycline
100mg
Under
6.0
0.125 dose
¼ tablet
0.125 dose
¼ tablet
See footnote2
Not
recommended
6.0 to
9.9
0.25 dose
½ tablet
0.25 dose
½ tablet
0.25 dose
¼ tablet
Not
recommended
10.0
to
15.9
0.375 dose
¾ tablet
0.375 dose
¾ tablet
0.25 dose3
¼ tablet
Not
recommended
16.0
to
24.9
0.5 dose
One tablet
0.5 dose
One tablet
0.5 dose
½ tablet
Not
recommended
25.0
to
44.9
0.75 dose
1-1/2 tablets
0.75 dose
1-1/2 tablets
0.75 dose
¾ tablet
Adult dose from
age 12 years
One tablet4
45
and
over
Adult dose
Two tablets
Adult dose
Two tablets
Adult dose
One tablet
Adult dose
One tablet
NB. Weight is a better guide than age for children, so weight should be used for
the purpose of children’s dosage calculation including children who are over- or
under-weight.
Further important notes:
 doxycycline is unsuitable for children under 12 years irrespective of their weight.
Caution: In other countries tablet strength may vary.
 atovaquone/proguanil paediatric dosage is given in Table 6
 As at July 2015, chloroquine syrup is not available in the UK
2
The SPC for mefloquine indicates that it can be used for those weighing more than 5 kgs.
Therefore, mefloquine (0.25 dose, ¼ tablet) may be advised for children weighing 5 to 9.9 kg.
3
For mefloquine at this weight, 0.375 dose would be preferable, but cannot be safely provided by breaking the
adult tablet.
4
The adult dose is necessary when doxycycline is only available in capsule form and 3/4 is not feasible.

34
Table 5 Table of doses by spoon or syringe
5
measures for chloroquine syrup
Weight in kilograms
Number of 5ml measures (there is
often a half size measure at the other
end of the spoon)
Proportion of adult dose
Under 4.5 0.5
(2.5 ml)
0.08
4.5–7.9 1.0
(5.0 ml)
0.16
8.0–10.9 1.5
(2.5 ml plus 5 ml)
0.24
11.0–14.9 2.0
(2 x 5 ml)
0.32
15.0–16.5 2.5
(2.5 ml plus 2 x 5 ml)
0.40
NB. These dose-steps are not the same as for chloroquine tablets, which differ
from the syrup in chloroquine content. Chloroquine syrup contains 50 mg
chloroquine base in 5 ml
Table 6 Table of paediatric dose of atovaquone/proguanil
Weight in kg
Proportion of adult
dose
Number of paediatric
tablets
5 to 7.9 0.125 ½ paediatric
8 to 9.9 0.188 ¾ paediatric
10 to 19.9 0.25 1 paediatric
40 and over 1.00 4 paediatric or 1 adult
See section 7.1 for advice on how to administer antimalarials to children.
5
Chemists may dispense dosing syringes for child doses.

35
4.4 Country recommendations
ACMP recommendations by country are summarised in Table 7
Key to Table 7:
A/P: atovaquone-proguanil combination preparation
BA only: bite avoidance plus awareness of risk
C: chloroquine
C+P: chloroquine plus proguanil
D: doxycycline
M: mefloquine.
Notes
1. Bite avoidance is advised even in malaria-free areas of the countries listed in this
table as a preventive measure against other insect vector-borne diseases
2. Some countries not listed in this table may experience occasional instances of
malaria transmission. Please check the NaTHNaC or TRAVAX websites regularly
for clinical updates
3. A recommendation for bite prevention plus awareness of risk does not mean there
is NO risk of malaria in the place in question, but indicates that ACMP considers the
level of risk to be below the threshold for routinely recommending
chemoprophylaxis. Where bite avoidance is now the main preventive measure for a
given area, rigorous adherence to the recommendations in Chapter 3 is strongly
advised. In all cases, whether or not chemoprophylaxis has been advised, special
attention must be given to bite prevention and febrile illness must be taken seriously
and investigated promptly.
4. The final decision whether or not to advise chemoprophylaxis rests with the travel
health advisor and the traveller after individual risk assessment has been
performed.Whilst the local malaria situation is the same for all travellers to a given
location, long-term VFR visitors run a higher risk. Furthermore, once infected, the
risk of developing severe or complicated malaria is higher in certain groups, eg the
elderly, those with complex co-morbidity and especially pregnant women.

36
Table 7 Country recommendations
Country name ACMP recommendations 2015
Afghanistan There is a risk of malaria below 2000m from May to
November (C+P). There is a low risk of malaria in this part of
the country during the rest of the year (BA only).
Algeria There is a very low risk of malaria in a small, remote focus in
the Illizi Department of Algeria (BA only). There is no risk in
the rest of Algeria.
Andaman and Nicobar
Islands (India)
There is a risk of malaria in the Andaman and Nicobar Islands
(BA only).
Angola There is a high risk of malaria in Angola (A/P,D, M).
Argentina There is a low risk of malaria in low altitude areas of Salta
provinces bordering Bolivia and in Chaco, Corrientes and
Misiones provinces close to the border with Paraguay and
Brazil (C only). There is no risk of malaria in Iguaçu Falls and
the rest of Argentina (BA only).
Armenia There is no risk of malaria in Armenia (BA only)
Azerbaijan There is low to no risk of malaria in Azerbaijan (BA only)
Bangladesh (see Figure 3) There is a high risk of malaria in the Chittagong Hill Tract
districts of Bangladesh (A/P,D, M). There is low to no risk in
the rest of Bangladesh (including Chittagong city) (BA only).
Belize There is a low risk of malaria in rural Belize (C only). There is
no risk of malaria in Belize district including Belize City and
islands frequented by tourists. (BA only)
Benin There is a high risk of malaria in Benin (A/P,D, M).
Bhutan There is a risk of malaria in the southern belt districts of
Bhutan along the border with India: Chukha, Geyleg-phug,
Samchi,
Samdrup Jonkhar and Shemgang (C+P). There is low to no
risk in the rest of Bhutan (BA only).
Bolivia There is a high risk of malaria in the Amazon basin of Bolivia
(A/P,D, M). There is a risk of malaria in other rural areas
below 2500m (C only). There is no risk above 2500m (BA
only).
Botswana There is a high risk of malaria, from November to June, in the
northern half of Botswana, including the Okavango Delta area

37
(A/P,D,M). There is a low risk of malaria in this part of the
country during the rest of the year (BA only). There is low to
no risk in the southern half of the country (BA only).
Brazil (see Figure 4) There is a risk of malaria in the Amazon basin of Brazil,
including in the city of Manaus (A/P,D, M). There is a very low
risk of malaria in the rest of Brazil (BA only). There is no risk
of malaria in Iguaçu Falls (BA only).
Brunei Darussalam There is very low risk of malaria in Brunei Darussalam (BA
only).
Burkina Faso There is a high risk of malaria in Burkina Faso (A/P, D, M).
Burundi There is a high risk of malaria in Burundi (A/P, D, M).
Cambodia There is a high risk of malaria in Cambodia. Chloroquine and
mefloquine resistance is widespread in the western provinces
of Cambodia bordering Thailand (A/P, D). Chloroquine
resistance is present in the rest of Cambodia (A/P, D, M).
There is a very low risk of malaria in the temple complexes of
Angkor Wat and around Lake Tonle Sap, including Siem
Reap (BA only). There is no risk in Phnom Penh (BA only).
Cameroon There is a high risk of malaria in Cameroon (A/P, D, M).
Cape Verde There is a very low risk of malaria on the Island of Santiago
(Sao Tiago) and Boa Vista (BA only).
Central African
Republic
There is a high risk of malaria in the Central African Republic
(A/P, D, M).
Chad There is a high risk of malaria in Chad (A/P, D, M).
China There is a high risk of malaria in Yunnan and Hainan
provinces in China (A/P, D, M). There is a very low risk of
malaria in southern and some central provinces, including
Anhui, Ghuizhou, Henan, Hubei, Jiangsu below 1500m (BA
only). The rest of China, including the main tourist areas and
cruises on the Yangtze river, are also very low risk (BA only).
China (Hong Kong) There is no risk of malaria in Hong Kong.
Colombia There is a high risk of malaria in most rural areas of Colombia
below 1600m (A/P, D, M). There is low to no risk in areas
above 1600m and in Cartagena (BA only).
Comoros There is a high risk of malaria in the Comoros (A/P, D, M).
Congo There is a high risk of malaria in the Congo (A/P, D, M).
Costa Rica There is a risk of malaria in Limon Province (C only) but not in

38
the city of Limon (Puerto Limon). There is a very low risk in
the rest of the country (BA only).
Côte d'Ivoire There is a high risk of malaria in the Cote d'Ivoire (A/P, D, M).
Democratic Republic of the
Congo
There is a high risk of malaria in the Democratic Republic of
the Congo (A/P, D, M).
Djibouti There is a high risk of malaria in Djibouti (A/P, D, M).
Dominican Republic There is a risk of malaria in all areas of the Dominican
Republic (C only), except in the cities of Santiago and Santo
Domingo (BA only).
East Timor (Timor-Leste) There is a high risk of malaria in East Timor (A/P, D, M).
Ecuador There is a risk of malaria in areas below 1500m, including the
coastal provinces and Amazon basin (A/P, D, M). There is no
risk of malaria in the Galapagos islands or the city of
Guayaquil.
Egypt There is no risk of malaria in Egypt (BA only).
El Salvador There is a low risk of malaria in rural areas of Santa Ana,
Ahuachapán and La Unión provinces in western El Salvador
(BA only). There is low to no risk in the rest El Salvador (BA
only)
Equatorial Guinea There is a high risk of malaria in Equatorial Guinea (A/P, D,
M).
Eritrea There is a high risk of malaria in Eritrea below 2200m (A/P, D,
M). There is no risk of malaria in Asmara or in areas above
2200m.
Ethiopia There is a high risk of malaria in Ethiopia below 2000m (A/P,
D, M). There is no risk of malaria in Addis Ababa or in areas
above 2000m.
French Guiana There is a high risk of malaria in French Guiana, particularly
in the border areas (A/P, D, M). There is no risk of malaria in
the city of Cayenne or Devil's Island (Ile du Diable). (BA only)
Gabon There is a high risk of malaria in Gabon (A/P, D, M).
Gambia There is a high risk of malaria in Gambia (A/P, D, M).
Georgia There is a very low risk of malaria in the rural southeast of
Georgia from June to October (BA only). There is no risk of
malaria in this part of the country during the rest of the year.
Ghana There is a high risk of malaria in Ghana (A/P, D, M).

39
Guatemala There is a low risk of malaria in Guatemala below 1500m (C
only). There is no risk in Guatemala City, Antigua and Lake
Atitlan and areas above 1500m.
Guinea There is a high risk of malaria in Guinea (A/P, D, M).
Guinea-Bissau There is a high risk of malaria in Guinea-Bissau (A/P, D, M).
Guyana There is a high risk of malaria in all interior regions of Guyana
(A/P, D, M).There is a very low risk of malaria in Georgetown
and the coastal region (BA only).
Haiti There is a risk of malaria in Haiti (C only).
Honduras There is a risk of malaria below 1000 m and in Roatán and
other Bay Islands (C only). There is no risk of malaria in San
Pedro Sula and Tegucigalpa and areas above 1000m.
India (see Figure 5) There is a risk of malaria sufficiently high to justify
chemoprophylaxis in the states of Assam and Orissa; the
districts of East Godavari, Srikakulam, Vishakhapatnam and
Vizianagaram in the state of Andhra Pradesh; and the
districts of Balaghat, Dindori, Mandla and Seoni in the state of
Madhya Pradesh (A/P, D, M).
For the rest of India (including Goa and the Andaman and
Nicobar Islands) ACMP no longer considers the risk of
contracting malaria sufficiently high to justify the use of
chemoprophylaxis (BA only).
There is no risk of malaria in the Lakshadweep islands.
Indonesia There is a high risk in Lombok and Irian Jaya (Papua) (A/P,
D, M). Risk in the rest of Indonesia (C+P). There is very low
risk in Bali, and the cities on the islands of Java and Sumatra
(BA only). There is no risk in the city of Jakarta.
Indonesia (Borneo) There is a high risk of malaria in Indonesian Borneo (A/P, D,
M).
Iran There is a risk of malaria from March to November in the rural
south eastern provinces of Iran and in the north, along the
Azerbaijan border in Ardabil and near the Turkmenistan
border in North Khorasan (C+P). There is low to no risk in the
rest of Iran. (BA only)
Iraq There is a very low risk of malaria in the rural northern area of
Iraq below 1500m, from May to November (BA only). There is
no risk in the rest of Iraq.

40
Kenya There is a high risk of malaria in Kenya (A/P, D, M). There is
very low risk in the city of Nairobi and in the highlands above
2500m (BA only).
Kyrgyzstan There is a very low risk of malaria in the southwest of
Kyrgyzstan, in areas bordering Tajikistan and Uzbekistan,
from June to October (BA only). There is no risk in the rest of
Kyrgyzstan.
Lao People’s
Democratic Republic
(Laos)
There is a high risk of malaria along the Laos-Myanmar
border in the provinces of Bokeo and Louang Namtha and
along the Laos-Thailand border in the province of
Champasak and Saravan (A/P, D).
There is a high risk of malaria in the rest of Laos (A/P, D, M).
There is low to no risk in the city of Vientiane (BA only).
Liberia There is a high risk of malaria in Liberia (A/P, D, M).
Libya There is no risk of malaria in Libya (BA only)
Madagascar There is a high risk of malaria in Madagascar (A/P, D, M).
Malawi There is a high risk of malaria in Malawi (A/P, D, M).
Malaysia There is a risk of malaria in the inland, forested areas of
peninsular Malaysia (A/P, D, M). There is a very low risk in
the rest of peninsular Malaysia, including the Cameron
Highlands and the city of Kuala Lumpur (BA only).
Malaysia (Borneo) There is a high risk of malaria in inland areas of Sabah and in
the inland, forested areas of Sarawak (A/P, D, M). There is a
very low risk of malaria in the rest of Malaysian Borneo
including the coastal areas of Sabah and Sarawak (BA only).
Mali There is a high risk of malaria in Mali (A/P, D, M).
Mauritania There is a high risk of malaria throughout the year in the
southern provinces of Mauritania (A/P, D, M). There is a high
risk of malaria in the northern provinces from July to October
inclusive (A/P, D, M). There is a low risk of malaria in the
northern provinces during the rest of the year (BA only).
Mauritius There is no risk of malaria in Mauritius (BA only)
Mayotte There is a risk of malaria in Mayotte (A/P, D, M).

41
Mexico There is a low risk of malaria in the states of Oaxaca and
Chiapas in southern Mexico (C only). There is a very low risk
of malaria in the states of Chihuahua, Durango, Nayarit,
Quintana Roo and Sinaloa and the rest of Mexico (BA only).
Mozambique There is a high risk of malaria in Mozambique (A/P, D, M).
Myanmar There is a high risk of malaria in Myanmar (A/P,D).There is
no risk in the cities of Mandalay and Yangon (BA only).
Namibia There is a high risk of malaria from November to June in the
northern third of Namibia (A/P, D, M). There is a low risk of
malaria in this part of the country during the rest of the year
(BA only). In the Caprivi Strip, Kavango and Kunene river
regions the risk is throughout the year (A/P, D, M). There is
low to no risk of malaria in the rest of Namibia (BA only).
Nepal There is a risk of malaria in areas of Nepal below 1500m,
particularly in the Terai district (C+P). There is no risk of
malaria in the city of Kathmandu and on typical Himalayan
treks (BA only).
Nicaragua There is a very low risk of malaria in Managua (BA only).
There is a low risk of malaria in the rest of Nicaragua (C
only).
Niger There is a high risk of malaria in Niger (A/P, D, M).
Nigeria There is a high risk of malaria in Nigeria (A/P, D, M).
North Korea There is a very low risk of malaria in some southern areas of
North Korea (BA only).
Pakistan There is a risk of malaria in areas of Pakistan below 2000m
(C+P). There is low to no risk above 2000m (BA only).
Panama There is a risk of malaria east of the Canal Zone in Panama
(C+P). There is a low risk of malaria west of the Canal Zone
(C only). There is no risk of malaria in Panama City or the
Canal Zone itself (BA only).
Papua New Guinea There is a high risk of malaria in Papua New Guinea below
1800m (A/P, D, M). There is low to no risk above 1800m (BA
only).

42
Paraguay There is a low risk of malaria in the departments of Alto
Paraná and Caaguazú (C only). There is a very low risk of
malaria in all other areas of Paraguay (BA only).
Peru There is a high risk of malaria in the Amazon basin of Peru
along the border with Brazil, particularly in Loreto province
(A/P, D, M). . There is a risk of malaria in the other rural areas
of Peru below 2000m including that part of the Amazon Basin
which borders Bolivia (C only). There is no risk in the city of
Lima and the coastal region south of Chiclayo (BA only)
Philippines There is a risk of malaria in rural areas of the Philippines
below 600m and on the islands of Luzon, Mindanao, Mindoro,
and Palawan (C+P). There is no risk in cities or on the islands
of Boracay, Bohol, Catanduanes, Cebu and Leyte (BA only).
Rwanda There is a high risk of malaria in Rwanda (A/P, D, M).
Sao Tome and Principe There is a high risk of malaria in São Tomé and Príncipe
(A/P, D, M).
Saudi Arabia There is a risk of malaria in the south western provinces of
Saudi Arabia, along the border with Yemen including Asir
province below 2000m (C+P). There is no risk in the cities of
Jeddah, Makkah (Mecca), Medina, Riyadh, and Ta’if, or in
Asir province above 2000m (BA only).
Senegal There is a high risk of malaria in Senegal (A/P, D, M).
Sierra Leone There is a high risk of malaria in Sierra Leone (A/P, D, M).
Singapore There is no risk of malaria in Singapore.
Solomon Islands There is a high risk of malaria in the Solomon Islands (A/P, D,
M).
Somalia There is a high risk of malaria in Somalia (A/P, D, M).
South Africa (see
Figure 6)
There is a moderate risk of malaria in South Africa from
September to May only in the low altitude areas of
Mpumalanga and Limpopo which border Mozambique and
Zimbabwe; this includes the Kruger National Park (A/P, D, M).
There is a low risk of malaria in northeast KwaZulu-Natal (BA
only). The areas bordering these are low risk (BA only).

43
South Korea There is a very low risk of malaria in the northern areas of
South Korea, in Gangwon-do and Gyeonggi-do Provinces,
and Incheon
City (towards the Demilitarized Zone or DMZ) (BA only).
South Sudan There is a high risk of malaria in South Sudan (A/P, D, M).
Sri Lanka There is a low risk of malaria in the area north of Vavuniya in
Sri Lanka (BA only). There is very low to no risk in the rest of
Sri Lanka (BA only). There is no risk of malaria in Colombo
and Kandy.
Sudan There is a high risk of malaria in the central and southern
parts of Sudan and a risk of malaria in the rest of the country
(A/P, D, M). There is a very low risk in Khartoum (BA only).
Suriname There is a high risk of malaria in Suriname (A/P, D, M). There
is a very low risk of malaria in coastal districts (BA only).
There is no risk in the city of Paramaribo (BA only).
Swaziland There is a high risk of malaria in the northern and eastern
regions bordering Mozambique and South Africa, including all
of the Lubombo district and Big Bend, Mhlume, Simunye and
Tshaneni regions (A/P, D, M).
There is a very low risk of malaria in the rest of the country
(BA only).
Syria There is a very low risk of malaria in small, remote foci of El
Hasaka (BA only).
Tajikistan There is a risk of malaria in Tajikistan from June to October,
in areas below 2000m (C+P). There is a low risk of malaria in
this part of the country during the rest of the year (BA only).
There is no risk of malaria above 2000m.
Tanzania There is a high risk of malaria in all areas below 1800m (A/P,
D, M).There is no risk of malaria above 1800m. There is a risk
of malaria in Zanzibar (A/P, D, M).

44
Thailand There is a high risk of malaria in the rural, forested borders of
Thailand with Cambodia, Laos and Myanmar (CQ and M
resistance) (A/P, D).
There is a very low risk of malaria in the remaining areas of
Thailand including Kanchanaburi (Kwai Bridge) (BA only).
There is no risk of malaria in the cities of Bangkok, Chiang
Mai, Chiang Rai, Koh Phangan, Koh Samui, and Pattaya (BA
only).
Togo There is a high risk of malaria in Togo (A/P, D, M).
Turkey There is a low risk of malaria in Turkey along the border plain
with Syria, around Adana and to the east of Adana from May
to October (C only). There is a very low risk of malaria in this
part of the country during the rest of the year (BA only).
The rest of Turkey, including most tourist areas, is very low
risk (BA only).
Uganda There is a high risk of malaria in Uganda (A/P, D, M).
Uzbekistan There is a very low risk of malaria in the extreme southeast of
Uzbekistan (BA only).
Vanuatu There is a risk of malaria in the whole of Vanuatu (A/P, D, M).
Venezuela There is a high risk of malaria in all areas of Venezuela south
of and including the Orinoco River and Angel Falls (A/P, D,
M). There is a risk of malaria in rural areas of Apure,
Monagas, Sucre and Zulia states (C+P). There is no risk in
the city of Caracas or on Margarita Island (BA only)
Vietnam There is a risk of malaria in the southern part of the country in
the provinces of Tay Ninh, Lam Dong, Dac Lac, Gia Lai, and
Kon Tum (A/P, D). There is also a risk of malaria in all other
rural areas of Vietnam (A/P, D).
There is a very low risk in the Mekong River delta (BA only)
until the border area with Cambodia There is no risk in large
cities, including Hanoi and Ho Chi Minh (Saigon), the Red
River delta, coastal areas north of Nha Trang and Phu Quoc
Island (BA only).
Western Sahara There is no risk of malaria in this country (BA only)

45
Yemen There is a risk of malaria in Yemen below 2000m (C+P).
There is very low risk of malaria on Socrota Island (BA only).
There is no risk of malaria above 2000m including Sana'a city
(BA only).
Zambia There is a high risk of malaria in Zambia (A/P, D, M).
Zimbabwe There is a high risk of malaria in Zimbabwe below 1200m
from November to June (A/P, D, M). There is a low risk of
malaria in this part of the country during the rest of the year
(BA only). In the Zambezi valley the risk is throughout the
year (A/P, D, M).There is very low risk in Harare and
Bulawayo (BA only).

46
4.5 Popular destinations
Figure 3 Map of Bangladesh showing the areas with appropriate malaria prevention measures recommended

47
Figure 4 Map of Brazil showing the states with appropriate malaria prevention measures recommended

48
Figure 5 Map of India showing the states with appropriate malaria prevention measures recommended
The new India and South Africa maps were provided by NaTHNaC; note that the format
is slightly different to the maps for Bangladesh and Brazil so check the key on the maps
carefully for correct interpretation of risk areas. In future updates of the guidelines, all
maps will be in the same format.

49
Figure 6 Map of South Africa showing the areas with appropriate malaria prevention measures recommended

50
4.6 Emergency standby treatment
Emergency standby treatment should be recommended for those taking
chemoprophylaxis and visiting remote areas where they are unlikely to be within 24
hours of medical attention.
It is intended for those travellers who believe that they may have malaria and is not a
replacement for chemoprophylaxis.
It is particularly important that the individual traveller is sufficiently well briefed to be able
to use standby emergency treatment appropriately, so written instructions for its use are
required (68).
Standby emergency treatment should be started if it is impossible to consult a doctor
and/or reach a diagnosis within 24 hours of the onset of fever.
Medical attention should be sought as soon as possible for full assessment and to
exclude other serious causes of fever. This is particularly important as many illnesses
other than malaria may present with fever.
The traveller should complete the standby treatment course and recommence their
antimalarial chemoprophylaxis 1 week after taking the first treatment dose, except in the
case of mefloquine prophylaxis, which should be resumed at least twelve hours after the
last treatment dose if quinine was used for standby treatment. Antipyretics should be
used to treat fever. A second full treatment dose of the antimalarial should be taken if
vomiting occurs within 30 minutes of taking it (half-dose if vomiting occurs after 30–60
minutes) (69).
The agent used for emergency standby treatment should be different from the drugs
used for chemoprophylaxis, both to minimise drug toxicity and due to concerns over
drug resistance (69).
Individuals for whom emergency standby treatment is advised must be provided with
written instructions for its use. In particular, they must be informed about symptoms
suggesting possible malaria, including fever of 38°C and above, indications for starting
the standby treatment, how to take it, expected side-effects and the possibility of drug
failure (69). ACMP recommended regimens for emergency standby treatment are given
in Table 8.
Dihydroartemisinin-piperaquine has only recently been licensed in the EU and there are
limited data on its use in travellers, so it cannot currently be recommended for this
indication.

51
Sulfadoxine/pyrimethamine (SP) is NOT recommended due to reports of widespread
resistance to this agent among P. falciparum strains. Halofantrine is no longer
recommended due to concerns over its association with sometimes fatal cardiac
arrhythmias (70).
Antimalarials purchased in the tropics may be fake (35) and travellers should obtain the
medication required for their emergency standby treatment from a reputable source in
the UK before they travel. ACMP also advises those purchasing antimalarial drugs over
the internet to ensure that they are dealing with a bona fide supplier or website.
Table 8 Emergency standby treatment for adults
Situation for use
Standby
treatment
regimen
Usual amount
per tablet
Adult dose
Chloroquine or
multi-drug resistant
falciparum malaria
Artemether plus
lumefantrine
combination
preparation
20 mg artemether
plus
120 mg
lumefantrine
4 tablets initially, followed by 5
further doses of 4 tablets each
given at 8, 24, 36, 48 and 60
hours.
Total 24 tablets over
a period of 60 hours
Tablets should be taken with
food to enhance drug
absorption.
Chloroquine or
falciparum malaria
Atovaquone
plus proguanil
combination
preparation
250 mg
atovaquone plus
100 mg proguanil
4 tablets as a single dose on
each of three consecutive
days
Chloroquine or
falciparum malaria
Quinine plus
doxycycline
300 mg quinine
100 mg
doxycycline
Quinine 2 tablets 3 times a
day for 3 days, accompanied
by 1 tablet of doxycycline
twice daily for 7 days
Pregnancy6
Quinine plus
clindamycin
300 mg quinine
150 mg
clindamycin
Quinine 2 tablets 3 times a
day for 5-7 days
Clindamycin 3 tablets (450
mg) 3 times a day for 5 days
Please see Appendix 3 for Emergency standby medication traveller information leaflet
which can be coped and pasted for use.
6
Pregnant travellers should avoid malarious areas. If that is not possible, quinine plus clindamycin is the only
regimen to be used in pregnancy.

52
5. Diagnosis
Suspected malaria is a medical emergency.
Consider malaria in every ill patient who has returned from the tropics in the previous
year, especially in the previous three months.
Fever on return from the tropics should be considered to be malaria until proven
otherwise.
Malaria cannot be diagnosed with certainty by clinical criteria alone. Suspected cases
should be investigated by obtaining a blood film diagnosis as a matter of urgency.
There is no need to wait for fever spikes before taking blood; this only delays diagnosis
and the fever pattern seldom conforms to text book periodicity, especially in the case of
Plasmodium falciparum.
5.1 Blood tests and how to request them in the UK
An EDTA-anticoagulated venous blood sample should be taken.
The sample should be received in the laboratory within one hour of being taken as
falciparum malaria may increase in severity over a few hours and the morphology of
malaria parasites in EDTA deteriorates over time, rendering accurate laboratory
diagnosis more difficult.
Finger-prick samples smeared directly onto microscope slides at the bedside are sub-
optimal for modern diagnosis as the laboratory then has no additional material to make
and stain further smears, undertake rapid diagnostic tests (RDTs) or refer for PCR
testing.
Laboratories in England, Wales and Northern Ireland making a diagnosis of malaria
should send blood films and a portion of the blood sample on which the diagnosis was
made to the PHE Malaria Reference Laboratory (MRL) for confirmation, see:
https://www.gov.uk/guidance/mrl-reference-diagnostic-and-advisory-services.
Laboratories in Scotland should refer to the Scottish Parasite Diagnostic Laboratory,
see: http://www.nhsggc.org.uk/about-us/professional-support-sites/scottish-
microbiology-reference-laboratories/scottish-parasite-diagnostic-reference-laboratory/

53
5.2 Rapid Diagnostic Tests (RDTs)
ACMP does not recommend travellers use Rapid Diagnostic Tests (RDTs) for self-
diagnosis.
RDTs, sometimes known as “dipsticks”, permit the detection of malaria parasites in
human blood without microscopy. Used correctly, they can confirm the clinical diagnosis
of malaria in places remote from medical attention (71) however there is evidence of
travellers being unable to use them correctly and thus failing to detect parasites (72).
RDTs do have a place in the medical kit carried by a doctor or nurse accompanying an
expedition to remote malarious regions. Performance of RDTs may be impaired if they
are stored at temperatures outside the recommended range (73). Therefore, care must
be taken to transport and store them correctly and thus prevent deterioration in their
performance in the field.
The WHO has an extensive product testing programme for RDTs. Prospective
purchasers should consult the WHO web site for information to inform their decision.
5.3 Blood film and/or RDT negative malaria
One negative blood film or RDT does not exclude a diagnosis of malaria. RDTs are not
a substitute for microscopy in UK practice, but have a useful role alongside blood films
as additional tests.
Where malaria is suspected blood films should be examined every 12 to 24 hours for 3
days whilst other diagnoses are also considered. If all these films are negative and
malaria is still considered a possible diagnosis, expert advice should be sought from a
specialist in tropical or infectious diseases. It is particularly important to seek such
advice early in the care of pregnant patients with suspected malaria, as the main
parasite biomass may be sequestered in the placenta such that peripheral blood films
are negative despite the patient having malaria (see Chapter 9 for expert advice listing).
5.4 Resources for treatment advice
The treatment of malaria is outside the scope of this document and is addressed in the
ACMP malaria treatment guidelines available at:
http://www.britishinfection.org/files/3514/1617/4227/malariatreatmentBIS07.pdf
Expert advice on malaria treatment may be obtained from:
 Hospital for Tropical Diseases: http://www.thehtd.org/
 Liverpool School of Tropical Medicine: http://www.liv.ac.uk/lstm/
 your local infectious diseases unit

54
5.5 Notification
Malaria is a statutorily notifiable disease in England and Wales and the clinician caring
for the patient must complete a notification form (74). In Scotland, malaria is not on the
list of notifiable diseases but Plasmodium is on the list of notifiable organisms. UK
laboratories outwith Scotland are also required to notify organisms they have
diagnosed. The legislation for notifiable organisms places duties on directors of
diagnostic laboratories to report organisms named in the list.
The Malaria Reference Laboratory (MRL) reporting form
(https://www.gov.uk/government/publications/malaria-report-form) should also be
completed and sent to the MRL separately or along with referred specimens.
6. Special groups (medical conditions)
6.1 Smoking cessation
Chloroquine or mefloquine should not be used in those taking Zyban® (bupropion
hydrochloride SR) as the chances of seizure may be increased.
6.2 Pregnancy
Pregnant women are advised to avoid travel to malarious areas.
In the event that travel is unavoidable, the pregnant traveller must be informed of the
risks which malaria presents and the risks and benefits of antimalarial
chemoprophylaxis.
Pregnant women have an increased risk of developing severe malaria and a higher risk
of fatality compared to non-pregnant women.
Diagnosis of falciparum malaria in pregnancy can be particularly difficult as parasites
may not be detectable in blood films due to sequestration in the placenta.
Expert advice is required at an early stage if malaria is suspected in a pregnant woman.
Complications, including severe anaemia, hypoglycaemia, jaundice, renal failure,
hyperpyrexia and pulmonary oedema, may ensue. The result may be miscarriage,
premature delivery, maternal and/or neonatal death.
Congenital malaria is rare, but occurs more commonly with P. vivax than with the other
malaria parasites of humans.

55
Avoidance of mosquito bites is extremely important in pregnancy as pregnant women
are particularly attractive to mosquitoes. Ideally, pregnant women should remain indoors
between dusk and dawn. If they have to be outdoors at night they should adhere
rigorously to bite precautions (see Chapter 3).
DEET should be used in a concentration of not more than 50%. DEET has a good
safety record in children and pregnancy (24) but ingestion should be avoided. Nursing
mothers should wash repellents off their hands and breast skin prior to handling infants.
See Chapter 3 for further details on DEET.
Chloroquine and proguanil
Safe in all trimesters of pregnancy. Their major disadvantage is the relatively poor
protection they give in many geographical areas due to the presence of drug-resistant
P. falciparum. Pregnant women taking proguanil should receive supplementation with 5
mg folic acid daily for at least the first trimester.
Mefloquine
Caution in first trimester, but can be used in all trimesters for travellers to high risk
areas. It seems unlikely that mefloquine is associated with adverse foetal outcomes
(75). There is no strong association between mefloquine in treatment doses (76, 77)
and stillbirths or miscarriages in the second and third trimesters.
A review of the manufacturer's global drug safety database covering 1986 to 2010
showed that for mefloquine exposure in pregnancy, the birth defect prevalence and
foetal loss in maternal, prospectively monitored cases were comparable to background
rates (78).
The decision whether or not to advise mefloquine prophylaxis in pregnancy always
requires a careful harm-benefit analysis. Where the levels of transmission and drug
resistance (see country tables in Chapter 4) make mefloquine an agent of first choice it
is generally agreed that mefloquine may be advised in the second and third trimesters
of pregnancy.
Given the potential severity of falciparum malaria in a pregnant woman, its use is also
justified in the first trimester in areas of high risk of acquiring falciparum malaria such as
sub-Saharan Africa (see Chapter 9).
Women who have taken mefloquine inadvertently just prior to or during the first
trimester should be advised that this does not constitute an indication to terminate the
pregnancy.

56
Doxycycline
Contraindicated in pregnancy. However, under special circumstances, if required before
15 weeks' gestation it should not be withheld if other options are unsuitable. The course
of doxycycline, including the 4 weeks after travel, must be completed before 15 weeks’
gestation
Atovaquone/proguanil
Lack of evidence on safety in pregnancy. Animal studies showed no evidence for
teratogenicity of the combination. The individual components have shown no effects on
parturition or pre- and post-natal development (Malarone SPC). ACMP advises against
the use of atovaquone/proguanil for antimalarial chemoprophylaxis in pregnancy.
However, if there are no other appropriate options, its use may be considered in the
second and third trimesters after careful risk assessment
Women who have taken atovaquone/proguanil inadvertently just prior to or during the
first trimester should be advised that this does not constitute an indication to terminate
the pregnancy.
Chemoprophylaxis prior to conception
If a female traveller is planning to conceive during a visit to a destination with a high risk
of contracting chloroquine-resistant falciparum malaria, expert advice should be sought.
Use of mefloquine may be considered after careful risk assessment.
Those travellers who plan to become pregnant after taking antimalarials and who wish
to do so with minimal antimalarial drug present, may elect to observe the following time
intervals after completing the course, before attempting to conceive:
Mefloquine: 3 months
Doxycycline: 1 week
Atovaquone/proguanil: 2 weeks
6.3 Breastfeeding
Mefloquine
Experience suggests safe to use during lactation
Doxycycline
The British National Formulary states that tetracyclines should not be given to women
who are breast feeding (54). A Centers for Disease Control Expert Meeting on Malaria
Chemoprophylaxis stated that doxycycline is excreted at low concentrations in breast
milk and that the American Academy of Pediatrics assessed tetracycline as compatible
with breast feeding (52). ACMP's view is that doxycycline should not be used in breast
feeding unless there is no alternative agent and its use is felt to be essential.

57
Atovaquone/proguanil
Not recommended because of the absence of data however, can be used when breast-
feeding if there is no suitable alternative antimalarial.
Nursing mothers should be advised to take the usual adult dose of antimalarial
appropriate for the country to be visited.
The amount of medication in breast milk will not protect the infant from malaria.
Therefore, the breastfeeding child needs his or her own prophylaxis. See Tables 4, 5
and 6 for paediatric doses.
6.4 Anticoagulants
6.4.1 The coumarins, including warfarin
Travellers should ensure their INR (International Normalised Ratio) is stable and within
the therapeutic range prior to departure and they have adequate supplies of their
anticoagulant for the whole trip. Changes in diet and alcohol intake can affect the INR.
Patients on warfarin may have underlying cardiovascular disease and may be on
cardiovascular medication. Interactions with other medication together with the
individuals' medical history should be taken into account when deciding on appropriate
malaria chemoprophylaxis.
Chloroquine
No interaction between warfarin and chloroquine documented in the BNF, although
there is a caution in the SPC for chloroquine.
Proguanil
An isolated report of an enhanced effect of warfarin when taken together with proguanil
(79).
Mefloquine
Not considered to be a problem for those taking warfarin. The manufacturer states that
'although no drug interaction is known with anticoagulants, effects of mefloquine on
travellers should be checked before departure.' Please see below for how this can be
monitored.
Doxycycline
The anticoagulant effect of coumarins (including warfarin) is possibly enhanced by
tetracyclines (54).

Guidelines for Malaria Prevention in Travellers from the UK 2015

Guidelines for Malaria Prevention in Travellers from the UK 2015

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Guidelines for Malaria Prevention in Travellers from the UK 2015